Telehealth Evaluation in the United States: Protocol for a Scoping Review

BACKGROUND

The rapid expansion of telehealth services, driven by the COVID-19 pandemic, necessitates systematic evaluation to guarantee the quality, effectiveness, and cost-effectiveness of telehealth services and programs in the United States. While numerous evaluation frameworks have emerged, crafted by various stakeholders, their comprehensiveness is limited, and the overall state of telehealth evaluation remains unclear.

OBJECTIVE

The overarching goal of this scoping review is to create a comprehensive overview of telehealth evaluation, incorporating perspectives from multiple stakeholder categories. Specifically, we aim to (1) map the existing landscape of telehealth evaluation, (2) identify key concepts for evaluation, (3) synthesize existing evaluation frameworks, and (4) identify measurements and assessments considered in the United States.

METHODS

We will conduct this scoping review in accordance with the Joanna Briggs Institute (JBI) methodology for scoping reviews and in line with the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews). This scoping review will consider documents, including reviews, reports, and white papers, published since January 1, 2019. It will focus on evaluation frameworks and associated measurements of telehealth services and programs in the US health care system, developed by telehealth stakeholders, professional organizations, and authoritative sources, excluding those developed by individual researchers, to collect data that reflect the collective expertise and consensus of experts within the respective professional group.

RESULTS

The data extracted from selected documents will be synthesized using tools such as tables and figures. Visual aids like Venn diagrams will be used to illustrate the relationships between the evaluation frameworks from various sources. A narrative summary will be crafted to further describe how the results align with the review objectives, facilitating a comprehensive overview of the findings. This scoping review is expected to conclude by August 2024.

CONCLUSIONS

By addressing critical gaps in telehealth evaluation, this scoping review protocol lays the foundation for a comprehensive and multistakeholder assessment of telehealth services and programs. Its findings will inform policy makers, health care providers, researchers, and other stakeholders in advancing the quality, effectiveness, and cost-effectiveness of telehealth in the US health care system.

TRIAL REGISTRATION

OSF Registries osf.io/aytus; https://osf.io/aytus.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/55209.

Adherence to the healthy eating index-2010 and alternative healthy eating index-2010 in relation to metabolic syndrome among African Americans in the Jackson heart study

OBJECTIVE

The primary objective of this study was to determine whether Healthy Eating Index (HEI) and Alternative Healthy Eating Index (AHEI) scores were associated with incident metabolic syndrome.

DESIGN

This study is a secondary analysis of data from the Jackson Heart Study. HEI and AHEI scores were divided into quintiles and Cox proportional hazards regression models were analysed for 1864 African American adults free from metabolic syndrome at Exam 1 to examine the incidence of metabolic syndrome by quintile of dietary quality score.

SETTING

Hinds, Madison and Rankin counties, Mississippi, USA.

PARTICIPANTS

African American adults, ages 21-94 years, 60·9 % female.

RESULTS

Over a mean follow-up time of 6·7 years, we observed 932 incident cases of metabolic syndrome. After adjusting for multiple covariates, a higher HEI score at Exam 1 was not associated with the risk of incident metabolic syndrome, except when looking at the trend analysis for the subgroup of adults with two metabolic syndrome components at Exam 1 (P-trend = 0·03). A higher AHEI score at Exam 1 was associated with the risk of incident metabolic syndrome (hazard ratio for those in the highest quintile compared to the lowest: 0·80 (95 % CI: 0·65, 0·99), P-trend = 0·03).

CONCLUSION

These findings suggest that a dietary pattern that scores higher on the AHEI may help reduce the risk of metabolic syndrome, even for adults who already have two of the minimum of three components required for a diagnosis of metabolic syndrome.

Economic evaluation and costs of remote patient monitoring for cardiovascular disease in the United States: a systematic review

BACKGROUND

Remote patient monitoring (RPM) has emerged as a viable and valuable care delivery method to improve chronic disease management. In light of the high prevalence and substantial economic burden of cardiovascular disease (CVD), this systematic review examines the cost and cost-effectiveness of using RPM to manage CVD in the United States.

METHODS

We systematically searched databases to identify potentially relevant research. Findings were synthesized for cost and cost-effectiveness by economic study type with consideration of study perspective, intervention, clinical outcome, and time horizon. The methodological quality was assessed using the Joanna Briggs Institute Checklist for Economic Evaluations.

RESULTS

Thirteen articles with fourteen studies published between 2011 and 2021 were included in the final review. Studies from the provider perspective with a narrow scope of cost components identified higher costs and similar effectiveness for the RPM group relative to the usual care group. However, studies from payer and healthcare sector perspectives indicate better clinical effectiveness of RPM relative to usual care, with two cost-utility analysis studies suggesting that RPM relative to usual care is a cost-effective tool for CVD management even at the conservative $50,000 per Quality-Adjusted Life-Year threshold. Additionally, all model-based studies revealed that RPM is cost-effective in the long run.

CONCLUSIONS

Full economic evaluations identified RPM as a potentially cost-effective tool, particularly for long-term CVD management. In addition to the current literature, rigorous economic analysis with a broader perspective is needed in evaluating the value and economic sustainability of RPM.

Quick on Your Feet: Modifying the Star Excursion Balance Test with a Cognitive Motor Response Time Task

The Star Excursion Balance Test (SEBT) is a common assessment used across clinical and research settings to test dynamic standing balance. The primary measure of this test is maximal reaching distance performed by the non-stance limb. Response time (RT) is a critical cognitive component of dynamic balance control and the faster the RT, the better the postural control and recovery from a postural perturbation. However, the measure of RT has not been done in conjunction with SEBT, especially with musculoskeletal fatigue. The purpose of this study is to examine RT during a SEBT, creating a modified SEBT (mSEBT), with a secondary goal to examine the effects of muscular fatigue on RT during SEBT. Sixteen healthy young male and female adults [age: 20 ± 1 years; height: 169.48 ± 8.2 cm; weight: 67.93 ± 12.7 kg] performed the mSEBT in five directions for three trials, after which the same was repeated with a response time task using Blazepod™ with a random stimulus. Participants then performed a low-intensity musculoskeletal fatigue task and completed the above measures again. A 2 × 2 × 3 repeated measures ANOVA was performed to test for differences in mean response time across trials, fatigue states, and leg reach as within-subjects factors. All statistical analyses were conducted in JASP at an alpha level of 0.05. RT was significantly faster over the course of testing regardless of reach leg or fatigue state (p = 0.023). Trial 3 demonstrated significantly lower RT compared to Trial 1 (p = 0.021). No significant differences were found between fatigue states or leg reach. These results indicate that response times during the mSEBT with RT is a learned skill that can improve over time. Future research should include an extended familiarization period to remove learning effects and a greater fatigue state to test for differences in RT during the mSEBT.

Cost of remote patient monitoring for cardiovascular disease: a systematic review protocol

OBJECTIVE

This review aims to evaluate the costs and cost-effectiveness of remote patient monitoring for cardiovascular disease in the United States.

INTRODUCTION

Cardiovascular disease is a leading public health concern in the United States, resulting in a substantial economic burden. Remote patient monitoring has emerged as a viable and valuable care delivery method to improve cardiovascular disease management at home. However, there is limited systematic research of the cost and cost-effectiveness of using remote patient monitoring to manage the disease.

INCLUSION CRITERIA

This review will consider all studies evaluating the cost of remote patient monitoring for cardiovascular disease management in the United States. The population of interest includes all individuals with various types of chronic cardiovascular disease in the United States.

METHODS

The search strategy will locate both published and unpublished studies. Systematic searches will be completed in PubMed, Embase, Web of Science, CINAHL, Scopus, Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, National Health Service Economic Evaluation Database, and the Cost-Effectiveness Analysis Registry. Two reviewers will independently screen titles and abstracts, followed by a full-text review against the inclusion criteria. Disagreements will be resolved through discussion between all study members. The JBI checklist for economic evaluations will be utilized to evaluate the methodological quality of studies. Data will be extracted using a modified version of the JBI data extraction form for economic evaluations. Reviewers will summarize studies and cost-related metrics. The Dominance Ranking Matrix will be used to synthesize full economic evaluation.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42021270621.

Use of Telehealth Services for Prenatal Care in Mississippi: Comparison of Pre-COVID-19 Pandemic and Pandemic Obstetric Management

BACKGROUND

The SARS-CoV-2 (COVID-19) pandemic resulted in major shifts in service delivery for patient care not involving COVID-19 illness. The preexisting telehealth infrastructure in Mississippi allowed the state to rapidly expand the scope of telehealth programs. Little research has been done to examine the use of telehealth during the COVID-19 pandemic and its impact on the delivery of care during pregnancy and outcomes associated with pregnancy. The objectives of this study are to (1) describe prenatal care practices during the height of the first wave of the COVID-19 pandemic, compared to the immediate prepandemic time period, and (2) explore maternal and birth outcomes during these time periods.

METHODS

This study was conducted as a retrospective historical cohort study from medical records at one Maternal Care Level IV (Regional Perinatal Health Care Center) in Mississippi and its affiliated centers. The participant cohort was inclusive of women who received prenatal care prior to a single birth delivery between May 1, 2020, and January 31, 2021. The pandemic cohort was defined through the timeframe of the included participants' end-term prenatal care, with reference to the beginning of the COVID-19 pandemic. The prepandemic cohort received a majority of their prenatal care prior to the COVID-19 pandemic.

RESULTS

There were 1,894 women included. Among them, 620 (32.77%) completed the majority of their end-term pregnancy in the pre-COVID-19 time period and 1,272 (67.23%) completed the end-term pregnancy during the pandemic. The odds ratio for patients from the pandemic cohort of scheduling telehealth visits compared to not scheduling telehealth visits is 8.19 (95% CI: 3.98, 16.86) times the odds ratio for patients from the prepandemic cohort. The pandemic exposure as well as infant's gestational age and very low birth weight (VLBW) show significant effects on the infant's living status in the univariate logistic regression. However, after controlling for the infant's gestational age and VLBW, we did not detect a significant effect of pandemic exposure.

CONCLUSION

This study demonstrated a very small reliance of telehealth for the medical supervision of pregnant women during the COVID-19 pandemic. This is likely because of the essential physical examinations that occur in women who are considered to be at high risk for poor maternal and birth outcomes. Additional studies on the impact of COVID-19 infection on maternal and infant outcomes are also needed as there may be important risk factors not yet identified for poor maternal or birth outcomes.

Social and Behavioral Factors Associated with BMI and Waist Circumference among Adolescents: The Jackson Heart KIDS Pilot Study

Background

African American children and adolescents make up a disproportionately large segment of those classified as overweight and obese. The purpose of this study was to examine social and behavioral factors associated with accelerated accumulation of weight and adiposity among this group.

Methods

The data for this cross-sectional study were drawn from the Jackson Heart KIDS Pilot Study - an offspring cohort study comprising 12- to 19-year-old descendants of Jackson Heart Study participants (N=212). Body mass index (BMI) and waist circumference were the outcomes of interest. Daily hassles, fruit and vegetable consumption, physical activity, television watching, parent/grandparent weight status and participant birth weight, age and sex were the independent variables included in the analyses.

Results

Males and females were equally represented in the study and the mean BMI and waist circumference for adolescents in the study was 25.81±7.78 kg/m² and 83.91 ± 19.81 cm, respectively. Fully adjusted linear regression models for the total sample produced results indicating that age, television viewing, weight control, and parental weight status were positively associated with BMI and waist circumference, respectively. Findings from sex-stratified models for BMI and waist circumference indicated that the significance of coefficients for age, television viewing, and parent/grandparent weight status varied by sex.

Conclusions

Knowledge is limited about how sex or gender interact with social and behavioral factors to influence African Americans' health and additional studies are needed to specify how these factors interact to accelerate weight gain and adipose tissue accumulation over the life course.

The Comparative Mental Health Responses Between Post-Musculoskeletal Injury and Post-Concussive Injury Among Collegiate Athletes: A Systematic Review

BACKGROUND

The average annual national estimate of injuries sustained by collegiate athletes is 210,674, which encompasses both those of a musculoskeletal and a concussive nature. Although athletic injuries are sustained through physical means and produce physical symptoms, sports-related injuries may be a stressor among athletes that is related to mental health.

PURPOSE

The purpose of this systematic review is to summarize existing literature describing mental health responses in collegiate athletes with a concussion compared to those with a musculoskeletal injury.

STUDY DESIGN

Systematic Review.

METHODS

Systematic searches of PubMed, CINAHL, Scopus, ProQuest, and SportDiscus were completed. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were utilized. Methodological quality was assessed using the Joanna Briggs Institute (JBI) Critical Appraisal Tool. Data extracted from the included articles included the study design, number of participants, type of injury, sex, age, sport participation, outcome measures, and time to return to play.

RESULTS

A total of six articles were included. Peak depressive symptoms in athletes who sustain a concussion or musculoskeletal injury occur within one-week post-injury. No significant differences between the concussive and musculoskeletal groups anxiety scores were found at baseline or at each follow-up session. Athletes from both groups were found to be returning to their respective sports with anxiety scores representative of clinical anxiety.

CONCLUSION

Similar trends in depressive and anxiety symptoms at various time points post-injury were observed in athletes with both musculoskeletal and concussive injuries. This study identified that athletes were returning to play before their psychological symptoms had returned to their baseline.

LEVEL OF EVIDENCE

2a.

Virtual immersive sensorimotor training (VIST) in collegiate soccer athletes: A quasi-experimental study

A burgeoning area of innovation in sports is the use of extended realities to provide athletes with novel training environments. Evidence has demonstrated that virtual environments can be useful therapeutic tools with demonstrated positive outcomes. The purpose of this pilot investigation was to determine the effects of virtual immersive sensorimotor training intervention by quantifying 1) the training effect measured via change in performance pre-to post-intervention on the virtual reality exercises, 2) the difference in the in clinical measures of functional sensorimotor control, 3) the injury incidence rate, and 4) on-field performance during soccer competitions. Statistical analyses were used to describe differences between an experimental and a control group. Participants were recruited from the men and women's soccer teams at two universities in the United States. Participants at one university were in the experimental group (n = 78) and received virtual immersive sensorimotor training, consisting of nine novel exercises in headset virtual reality, twice each week for six weeks. Participants at the second university were in the control group (n = 52). The virtual exercises were developed with reference to the rehabilitative principles of neuroplasticity to train various neurologic processes, contributing to overall sensorimotor control. This includes vestibular, visual and oculomotor activities, cervical neuromotor control training, movement coordination, and postural/balance exercises. The results indicate significant positive training effects pre-to post-intervention in seven of the nine training exercises (p ≤ 0.005) and improvement in clinical tests of cervical neuromotor control, balance, and inspection time (p ≤ 0.009) in the experimental group compared to the control. One of the virtual training exercises was positively associated with on-field performance (p = 0.022). No differences in injury rate or overall on-field performance metrics between the experimental and control were detected. This research study provides evidence of training and positive transfer from virtual to real-world environments, supporting the use of these novel virtual exercises to improve measures of sensorimotor control in healthy soccer athletes.

Physical Activity and Pain in Youth With Sickle Cell Disease

Study objectives were to examine the relationships between physical activity, pain, and psychological distress in youth 8 to 17 years of age with sickle cell disease. Participants were 206 youth with sickle cell disease (M = 11.73 years, 54.9% female, 99.5% African American). Caregivers and youth completed a clinical psychosocial screening battery. Results revealed frequent pain (37.6%), moderate median pain intensity, and elevated median pain interference in youth. Lower caregiver-reported physical activity was associated with worse pain outcomes. Increased anxiety was also associated with worse pain outcomes. A better understanding of the relationship between physical activity/inactivity and pain will guide multifactorial treatment interventions.

Sensorimotor training for injury prevention in collegiate soccer players: An experimental study

OBJECTIVES

Deliver a sensorimotor training intervention; quantify the change in clinical measurements of sensorimotor control; and compare injury rate to a historical control.

DESIGN

One-arm experimental pilot; Level 3.

SETTING

NCAA Division II university athletic facilities.

PARTICIPANTS

75 collegiate soccer players (38 males; 37 females) were enrolled, including 30 (40%) with history of concussion, and participated in eight training sessions.

OUTCOMES

Change in pre-to post-intervention for: static balance on the Sway app, near-point convergence, self-reported symptoms on the Post-Concussion Symptom Scale, cervical flexor neuromotor control/endurance, measured by the Cranial-Cervical Flexion Test and Joint Position Error test, and gaze stability on the Dynamic Visual Acuity Test. Injury incidence rate in 2018 was calculated using the number of traumatic injuries across the season and athlete exposure counts, as compared to a historical control.

RESULTS

Significant improvements were obtained in static balance, cervical flexor neuromotor control/endurance, and near-point convergence (p-values<0.01-0.03). Increases in symptom report (p = 0.02) and a decline in dynamic gaze stability (p < 0.01) were observed. There were 11.8 injuries/1000 athlete exposures in 2017 and 8.9 injuries/1000 athlete exposures in 2018 after the treatment (p = 0.18).

CONCLUSION

This intervention holds promise as a preventive strategy for sports-injury as a comprehensive population-based intervention.

Validity of the 8-Foot Up and Go, Timed Up and Go, and Activities-Specific Balance Confidence Scale in older adults with and without cognitive impairment

The purpose of this study was to determine whether (1) mild cognitive impairment (MCI) alters the validity of the Timed Up and Go (TUG), the 8-Foot Up and Go (8UG), or the Activities-Specific Balance Confidence (ABC) scale in the identification of fallers and nonfallers and (2) there were differences in the concurrent validity between the TUG and ABC when compared with the 8UG and ABC in those with and without MCI.. The classification of MCI was based on a score of <26 points on the Montreal Cognitive Assessment. For the 62 participants enrolled, excellent correlations were demonstrated in pairwise comparisons between the outcome measures (on a continuous scale). Based on frequently cited cutpoints, the sensitivity of the TUG was only 20% with a specificity of 94.6% and the sensitivity of the 8UG was 64% with a specificity of 75.7%. The TUG identified fallers at significantly different rates than the 8UG and the ABC (p < 0.05). For this reason, the 8UG is recommended as a more appropriate outcome measure for identifying fall risk in community-dwelling older adults. Fall history was found as the only significant predictor of test outcome for the TUG, 8UG, and ABC, indicating that MCI is not a significant determinant of test performance.

Physical examination of dizziness in athletes after a concussion: A descriptive study

BACKGROUND

Dizziness is commonly reported after concussion. With the forces experienced at the time of the injury, several anatomical locations may have been altered, causing dizziness.

OBJECTIVE

Describe an objective examination and the types of impairment/dysfunction implicated by the results of clinical examination tests in subjects with dizziness after a concussion.

DESIGN

Cross-Sectional.

METHODS

Athletes between ages 10-23 were enrolled with a diagnosis of concussion. An examination was completed to identify areas potentially contributing to dizziness, including tests of oculomotor control, the vestibular system, neuromotor control, and musculoskeletal components of the cervical spine. Descriptive analyses were completed to define the anatomical areas/types of dysfunction identified by positive findings of the examination tests.

RESULTS

All (n = 41; 100%) subjects had examination findings consistent with central dysfunction. Of these, 36 (97.8%) had oculomotor control deficits; 29 (70.7%) demonstrated motion sensitivity; and 6 (15%) had central vestibular deficits. Nineteen (46.3%) had peripheral dysfunction, including 18 (43.9%) with unilateral hypofunction, and 2 (4.9%) with Benign Paroxysmal Positional Vertigo. Thirty-four (82.9%) had cervical dysfunction, with 11 (26.8%) presenting with cervicogenic dizziness, and 31 (75.6%) with altered neuromotor control.

CONCLUSIONS

Functional injury to centrally-mediated pathways, specifically oculomotor control, and afferent and efferent pathways in the cervical spine are commonly identified through clinical examination tests in individuals with a complaint of dizziness post-concussion. According to results presented here, a high majority (90%) of the participants demonstrated dizziness that appeared to be multifactorial in nature and was not attributable to one main type of dysfunction. The common pathways between the systems make it difficult to isolate only one anatomical area as a contributor to dizziness.

Effectiveness of kinesiology tape on sports performance abilities in athletes: A systematic review

OBJECTIVE

Establish the effectiveness of kinesiology tape (KT) on sports performance abilities compared to that of other tapes or no tape with consideration to the application methodology, timeframe, and outcome measurement.

METHODS

PubMed, Embase, and PEDro databases were systematically searched. The following inclusion criteria were applied: 1) participants were healthy athletes, 2) compared any brand of dynamic KT to other types of tape (sham or therapeutic) and/or no tape, 3) measured some construct of functional sports performance, 4) involved randomization. The PEDro scale was used to grade the risk of bias.

RESULTS

Fifteen studies met the inclusion criteria with PEDro scores ranging from 3 to 8 of 10 points. The sports performance abilities included: ball skills; power squats; cycling; dynamic balance; jumping (vertical and horizontal); agility; sprint speed; and distance running with 193 comparisons between KT and other tapes or no tape at a variety of timeframes after application. In total, eleven comparisons demonstrated significant effects: 2 in favor of KT, 8 in favor of Mulligan's tape, and one in favor of no tape.

CONCLUSION

There is a lack of compelling evidence to support the use of KT to enhance the sports performance abilities based on this review.

LEVEL OF EVIDENCE

1a-.

Feasibility of early physical therapy for dizziness after a sports-related concussion: A randomized clinical trial

The purpose of this study was to (a) assess the feasibility of recruitment/retention of participants, protocol/resource management, and participant safety, and (b) estimate the size of the effect between the experimental and control groups. This was a feasibility study conducted as a prospective pilot double-blind randomized clinical trial. Subjects aged 10-23 years old with acute concussion and dizziness were enrolled from sports medicine centers. Forty-one participants were randomized into treatment and were seen for physical therapy beginning at 10 days post-concussion. Subjects in the experimental group received individually tailored, pragmatically delivered progressive interventions. Subjects in the control received prescriptive sham to minimally progressive interventions. The two primary outcomes were medical clearance for return-to-play and symptomatic recovery. The median number of days to medical clearance for the experimental group was 15.5 and for the control was 26. The median number of days to symptomatic recovery was 13.5 for the experimental group and was 17 for the control. According to Cox proportional hazards regression for time to medical release for return-to-play, the experimental group demonstrated a hazard ratio of 2.91 (95% CI: 1.01, 8.43) compared to the control. For time-to-symptomatic recovery, those in the experimental group demonstrated a hazard ratio of 1.99 (95% CI: 0.95, 4.15) compared to the control. The results indicate that it is feasible and safe to complete this type of intervention study. The results provide strong support for the allocation of resources to conduct well-powered randomized clinical trials of this intervention.

Effects of an integrated geriatric group balance class within an entry-level Doctorate of Physical Therapy program on students' perceptions of geriatrics and geriatric education in the United States

This study was aimed at determining the effect of an integrated group balance class for community-dwelling older adults within entry-level physical therapist coursework on student perceptions of geriatric physical therapy and geriatric physical therapy education. Twenty-nine Doctor of Physical Therapy (DPT) students, 21-33 years old, in their second year of coursework in 2012, participated in an integrated clinical experience with exposure to geriatric patients at an outpatient facility at the Louis Stokes Cleveland Department of Veterans Affairs Medical Center in Akron, Ohio, USA. Student perceptions were collected before and after participation in the 8-week balance class. The Wilcoxon sign-ranked test was used to identify differences in perceptions after participation in the group balance class. Cohen's d values were calculated to measure the size of the pre-participation to post-participation effect for each measure. At the conclusion of the group class, the DPT students demonstrated an increase in positive perceptions of geriatric physical therapy in 8 measures, with small effect sizes (d=0.15-0.30). Two perceptions of geriatric physical therapy demonstrated a significant positive increase (P<.05) with moderate effect sizes (d=0.47 and d=0.50). The students' perceptions of geriatric education in the curriculum demonstrated a large positive effect for quality (d=1.68) and enjoyment (d=1.96). Positive changes were found in most of the perceptions of geriatrics and geriatric education after participation, suggesting that integrated clinical experiences with geriatric patients are an effective way to positively influence perceptions of physical therapist practice with older adults.

Differential diagnosis of dizziness after a sports-related concussion based on descriptors and triggers: an observational study

Background

Dizziness is often reported after a sports-related concussion. Forces experienced at the time of the concussion can cause an injury to multiple anatomical areas, including the central nervous system, the vestibular system, and the cervical spine, each of which is sufficient to cause dizziness. Medical professionals routinely use the subjective history to develop hypotheses about what may be causing a patient’s dizziness. No previous studies have attempted to differentiate the source of the dizziness through precise patient descriptors or the triggers of dizziness.

Methods

A structured symptom questionnaire was developed through purposive exploration of relevant literature for common dizziness quality descriptors and triggers. This questionnaire was used to interview a sample of 86 adolescent athletes (12–19 years of age) with a sports-related concussion between August 2013 and April 2014. Exploratory Latent Class Analysis was used to uncover latent constructs within the 15 dizziness descriptors and 11 dizziness triggers. The covariates sex, attention deficit hyperactivity disorder, and number of days between the concussion and the assessment were added to the model to estimate if these variables influenced class membership probabilities.

Results

Thirty-two (36 %) of the patients interviewed did not report a complaint of dizziness but did affirm one or more of the other descriptors. Three classes of dizziness based on dizziness quality descriptors and three classes based on dizziness triggers were identified by the analysis. Neither the classes of descriptors nor the classes of triggers enabled differentiation based on anatomical etiology of the dizziness.

Conclusions

Patient description of dizziness is limited in its ability to assist in differential diagnosis based on anatomical location for athletes with concussion. This may be because more than one area is contributing to the dizziness or because concussed adolescents have difficulty describing the way that they feel. In this case, solely relying on the patient to provide a description of dizziness to develop the formation of hypotheses and lead the direction of objective tests is inappropriate. If the scope of the objective assessment is limited by the patient description of dizziness, it is likely that areas of dysfunction may be overlooked.

The relationship between adherence behaviors and recovery time in adolescents after a sports-related concussion: an observational study

BACKGROUND

Adherence to rehabilitation is widely accepted as vital for recovery and return to play following sports injuries. Medical management of concussion is centered around physical and cognitive rest, a theory largely based on expert opinion, not empirical evidence. Current research on this topic focuses on factors that are predictive of adherence to rehabilitation, but fails to examine if patient adherence leads to a better outcome. The purpose of this study was to determine the adherence tendencies of adolescents to treatment recommendations provided by a sports-medicine physician after a concussion and to determine if adherence to each recommendation was a predictor of treatment duration.

STUDY DESIGN

Observational.

METHODS

Participants were enrolled in the study at their initial visit to the Sports-Medicine Center for medical care after a sports-related concussion. Individual treatment recommendations provided by a sports-medicine physician for concussion were recorded over the course of each participant's care. Once released from medical care, each participant was contacted to complete an online questionnaire to measure self-reported adherence tendencies to each treatment recommendation. Adherence was measured by two constructs: 1) the reported receptivity to the recommendation and 2) the frequency of following the recommendation. Exploratory univariate Poisson regression analyses were used to describe the relationship between adherence behaviors and the number of days of treatment required before the participant was returned to play.

RESULTS

Fifty-six questionnaires were completed, by 30 male and 26 female adolescent athletes. The self-reported adherence tendencies were very high. None of the measures of adherence to the treatment recommendations were significant predictors of the number of days of treatment; however, there was a clear tendency in five of the six rest parameters (physical rest, cognitive rest with restrictions from electronics, and cognitive rest with restrictions from school), where high levels of adherence to rest resulted in an increased average number of days of treatment (slower recovery) and those who reported being less adherent recovered faster.

CONCLUSIONS

Adolescents were generally adherent to the physician recommendations. Those participants who reported being less adherent to physical and cognitive rest generally recovered faster than those who reported higher levels of adherence to these recommendations. As time progresses after the initial injury, physical and mental rest may be less effective to hasten recovery than more active treatment recommendations.

LEVEL OF EVIDENCE

Level 2.

The diagnostic utility of clinical tests for differentiating between cervicogenic and other causes of dizziness after a sports-related concussion: An international Delphi study

OBJECTIVES

Dizziness after a sports-related concussion is very common and is associated with prolonged recovery. The events in sports that cause concussion include strong mechanical forces exerted to the head and neck, potentially injuring the cervical region, the peripheral vestibular and central nervous system, all of which can contribute to a sensation of dizziness. The purpose of this study was to identify proper clinically administered tests and measures that are useful in differentiating between cervicogenic and other causes of dizziness after a sports-related concussion.

DESIGN

The Delphi method.

METHODS

The workgroup identified the initial list of suggested clinical tests and the initial list of content experts on dizziness and/or concussion through a search of peer-reviewed and grey literature. The respondent group included all invited experts who opted to participate. A sequential three-round process was used for elicitation of consensus opinions from the targeted content experts.

RESULTS

The respondent group included 25 members from several medical disciplines who were experts in concussion and dizziness. At the conclusion of the study, ten clinical tests achieved the designation of strong clinical utility, six were determined to have weak clinical utility and seven achieved no consensus among the experts.

CONCLUSIONS

The majority of clinical tests identified as having strong clinical utility are tests used to identify dizziness originating from the vestibular or central nervous system. No clinical tests specific for the cervical region achieved consensus. Expert opinion from different medical professions and even within professions was widely divergent regarding the utility of clinical tests to assess cervical dysfunction.

The effectiveness of physical therapist-administered group-based exercise on fall prevention: a systematic review of randomized controlled trials

BACKGROUND

Falls are a verified cause of morbidity and mortality in adults older than 65 years. Exercise under the direction of a physical therapist has been shown to reduce the risk of falls in older adults; however, it is not clear whether physical therapist-directed group-based exercise could produce similar results.

PURPOSE

The purpose of this systematic review was to summarize the evidence on the effectiveness of physical therapist-administered group-based exercise when compared with various controls for falls prevention and improvement of quality of life.

METHODS

A computerized search of PubMed and CINAHL was performed. An exhaustive hand search was also performed of the references of all full-text articles. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed for this review. Studies were included if they met the following criteria: (1) comparison of group-based exercise led by a physical therapist to a control group; (2) ambulatory elderly men or women, aged 65 years or older; (3) subjects in the community or institutional setting; (4) the use of 1 or more outcome measures related to functional balance and/or quality of life; (5) randomized controlled or clinical trials; and (6) published in English, between December 1, 2001, and June 7, 2012. The PEDro scale was used to assess the quality of each study included in this review.

RESULTS

The computerized search strategy and hand search revealed 213 potential articles, 10 of which met the inclusion criteria. After assessment with the PEDro scale, 8 of these were considered high-quality studies (score > 6/10). Seven studies compared group-based exercise to a nonexercise control group, while 3 studies compared group-based exercise with a physical therapist-prescribed home exercise program. Outcomes measured include fall rate, balance, physical performance, health-related quality of life, and fear of falling.

DISCUSSION

When group-based exercise was compared with no intervention, group-based exercise was found to be more effective in decreasing fall frequency, increase balance, and improve quality of life. When compared with a physical therapist-prescribed home exercise program, the group-based exercise results were not statistically different but showed improvements in some quality of life and physical functioning measures. There is also some evidence to suggest that group-based exercise promotes greater patient satisfaction and exercise adherence.

CONCLUSION

There is preliminary evidence to suggest that the group-based exercise is effective for falls prevention, quality-of-life enhancement, and balance improvements in the older adults comparable with traditional home exercise programs.